Every so often, the reality of trying to maintain a career in science-based medicine interferes with the fun that is writing for this blog. Basically, what happened is that I spent the entire weekend working on three different grant applications and, by the time Sunday night rolled around, I was too exhausted to write what I had originally planned on writing. Fortunately, one advantage of having been blogging so long and also having blogged under a pseudonym over at my not-so-super-secret other blog is that there’s a lot of material which is pretty damned good, if I do say so myself, that I can draw on for just these situations. Even better, it’s old enough that it’s unlikely that most of you have actually come across it before, which makes it new to you (well, at least most of you). As a special bonus, the jumping off point was a post by an occasional contributor to this blog, Peter Lipson. Actually, I wish Peter would contribute more regularly, but he’s too busy moving on to bigger things at Forbes.

This time around, I’m half-recycling, half-revising a post that was a bit more navel-gazing than usual. However, as the only surgeon on SBM I think it’s actually useful every now and then to discuss the trials and tribulations of practicing science-based surgery. It began when Peter wrote an excellent meditation on a topic that’s always been a difficult issue for me to face as a surgeon, namely how one balances confidence in one’s ability with humility in the face of disease and uncertain science. He started with a spot-on observation:

The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor’s natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge.

Peter then went on to describe how he tries to teach physicians-in-training the right balance and does an excellent job of it. He’s absolutely right about pushing residents to make a decision and justify it to the attending, trying to get them to think like an attending who knows that the buck stops with him or her while they are still in the safe confines of the training program, with a real attending covering their backs.

In surgery, I think, the mix is different. Surgeons have to project confidence to their patients because the technical skill involved makes surgery and other procedure-driven specialties somewhat different. It’s not just about knowing the science. It’s about being good at the technical skills that are so important in surgery. As much as it might be denied, proposing a course of treatment that involves cutting into a person and rearranging his or her anatomy for therapeutic effect is perceived differently by patients than proposing they take a new medication or even undergoing chemotherapy. It’s far more invasive and far more dependent on the raw skill of the practitioner. Teaching surgery is also different than teaching internal medicine because there are two elements involved. Like the case for medical specialties, there is the cognitive element, teaching diagnostic skills and the appropriate therapies for various diseases and conditions. However, in addition to these cognitive skills that must be taught, there is also a huge base of technical skills that must be mastered. It’s true that internists and other physicians must also learn a number of technical skills, such as placing IVs and central lines, doing lumbar punctures or bone marrow biopsies, and tapping pleural effusions, but, even in the more procedure-oriented internal medicine specialties, the number and level of invasiveness of these procedures are nowhere near what surgeons must learn. In brief, no therapy can mess a patient up if it goes wrong quite like surgery, and every surgeon who does large cases has at some point in his career messed up a patient. That doesn’t make them bad surgeons; it’s the nature of the beast. No matter how good a surgeon is, complications are inevitable. How many complications and how the surgeon deals with them are what separate good from bad surgeons.

This realization makes the proper balance between confidence and arrogance arguably more difficult to reach. We surgeons have all encountered at some time in our careers the “cowboy” surgeon. This variety of surgeon seemingly has no fear and will plunge into even the most difficult and dangerous cases (“The patient has diabetes, severe coronary artery disease with an ejection fraction of 25%, COPD, and is on aspirin and Plavix? No problem! Let’s operate!”), seemingly oblivious to the risk. He not infrequently gets into trouble (“Oops, I severed the aorta! Don’t worry. I can fix this.”) but usually manages to get out of it, seemingly unfazed by the experience and the close call that the patient had. In contrast, we have also all encountered the excessively cautious surgeon, the one who often hesitates and seems almost afraid to operate, even when the situation calls for, as I like to put it, maximal invasiveness. Both are extremes that a surgeon should try to avoid.

Add to this mix patient expectations. When I first started practicing after leaving my fellowship, I thought that the best approach was to lay out the surgical options, the risks and benefits of each based on my best interpretation, and to try to let the patient decide, with my advice as needed. I soon found that this was a problem. Reports came back to me through my division chief that some patients viewed me as indecisive and didn’t have the confidence in me necessary to let me operate on them. Then I learned that this wasn’t the case for all patients. Some genuinely liked this approach because to them it respected as much as possible their autonomy. Others hated this approach because they had expectations of what a surgeon should be, and those expectations included telling them what needed to be done and just doing it. No doubt the same is true of patients in other specialties, but the sheer invasive and personal nature of surgery tends to shift the balance of patient expectations more towards the paternalistic model. Surgeons see things in a patient that even their spouses never see, namely their insides, and this, coupled with the knowledge that it is the skill of one individual that can determine success or failure of even the correct course of action, makes surgery very intimate and personal to the patient.

What I eventually learned was that not only does a surgeon have to find the right mix between paternalism and doing what the patient wants, between confidence and arrogance, all the while choosing courses of action that are supported by science, the surgeon must also be able to size up patients to figure out what specific balance between these competing traits each individual patient expects and then titrate his behavior accordingly. Some patients really do just want the surgeon to tell them what needs to be done and then to do it, without all that confusing discussion of options based on the surgical and scientific literature. Such patients frequently ask the question, “What would you recommend if I were your wife/mother/sister?” The surgeon had better be able to give the answer to that question with confidence and still tell the patient enough about the risks to obtain truly informed consent. Others want a full discussion to the point of wanting references from the peer-reviewed scientific literature, in which case the surgeon has to titrate his demeanor to a less paternalistic manner. I like to think I’ve gotten better at this in the last 15 years. Certainly I haven’t heard word of patients viewing me as indecisive in a while. (Cue a patient finding this blog and telling me how wishy-washy I am.)

In terms of training, the way Peter described training young physicians is certainly operative–if you’ll excuse the term–in training surgeons in the nonsurgical skills of diagnosis and nonoperative treatments of surgical diseases. Indeed, the best teachers I ever had did exactly that. Many are the times I recall calling an attending in the middle of the night and, after telling him about the patient, hearing the response, “OK, what do you want to do now?” Woe be unto me if I didn’t have a well-reasoned plan of action. Indeed, it was better to have a bad plan of action than to stammer back, “I don’t know.”

The differences between surgical and medical training become most apparent in the operating room. The art of teaching a young surgeon how to operate is incredibly difficult. Indeed, when I was a resident, I never appreciated just how difficult it is for a surgeon to take a resident through a case and keep his or her sanity. Now that I’m on the other side of the operating table, I know. When the resident falters, there is a very strong tendency to want to grab the instruments and take over the case, but doing so too quickly will prevent the resident from learning how to do difficult dissections or to handle other difficulties encountered in the OR. On the other hand, patient safety must be paramount. Letting the resident struggle too long (for instance, trying to dissect a structure free from a large blood vessel) runs the very real risk of harming the patient, and that can never be allowed. I remember well one attending that I had whose wisdom I didn’t appreciate at the time. He leaned more towards the “cowboy” type of surgeon but his skills were so legendary that he really could almost always get himself out of any trouble that he found himself in. He forced residents beyond what they thought they could do, although he frequently yelled as they did it. What I realized later is that he was just so technically gifted that it drove him crazy to watch me and other residents clumsily try to do what he could do with slickness and utter aplomb, but he restrained himself from taking over the case unless the patient was in danger because he was just that dedicated to teaching. He also taught me a number of things that no other attending did, such as how to take down bowel adhesions with the knife instead of bluntly or with scissors, how to do a Stoppa hernia repair, and a number of other maneuvers that I still use to this day.

Another aspect of surgery that makes it difficult to avoid arrogance is that surgeons tend to have a mentality that surgery can fix things. And fix things it most definitely can, sometimes in a truly dramatic and satisfying fashion. The problem is, however, that because it is so difficult (and often impossible) to do truly “gold standard” randomized, double-blind studies on surgical therapies, the level of evidence supporting them is often based on a preponderance of retrospective studies and other inferences. This makes surgery, at least in my experience, more prone to the persistence of dogma beyond when scientific and clinical evidence doesn’t support a therapy anymore. Surgery residencies also tend to function in a much more hierarchical manner; indeed, I have often likened them to the military, with a clear chain of command that is violated at one’s peril. Interns usually don’t go straight to the attending without going through the chief resident first, and orders tend to flow downhill from the attending, to the chief or senior resident, all the way down to the junior residents. Medicine residencies tend to be different, with less of an emphasis on rank. It’s not that rank doesn’t matter; it’s just that it doesn’t seem as rigid as in surgery residencies. Although it is changing, probably in response to overall societal changes that are less tolerant of rigid authority structures and mandated work hour limitations for residents, which increasingly force attendings to deal with whatever resident is there (often an intern), vestiges of a military-like hierarchy still remain and likely will remain. This can lead to what I call “tradition-based” surgery, typified by the remark, “This is how I was taught to do it and how I’ve always done it.”

The flip side of this ability to “fix” things is that surgeons really do love bright, shiny, new surgical procedures and technology. In other words, surgeons (as a specialty) have a distressing tendency to be susceptible to “bandwagon” effects. I’ve written about this before with respect to the rapid adoption of laparoscopic cholecystectomy years before clinical data demonstrated it to produce equivalent relief of symptoms with an acceptable complication rate. “On the ground,” laparoscopic cholecystectomy looked so dramatic in its ability to alleviate symptoms of gallbladder disease with a greatly decreased level of pain and time to recovery from surgery, but until the clinical studies were done it was impossible to know if the long term complication rate, particularly the rate of bile duct injuries, was unacceptably high. To balance this out, however, I’d be remiss if I didn’t mention once again that some of the best and most rigorous controlled studies (such as in breast cancer surgery) were done by surgeons. These two tendencies are often in conflict in surgery and must be balanced, and it’s not easy.

It takes years of training to develop the decision-making skills that go into being an effective attending physician.

This is one place where we part ways with the cranks and quacks.

Cranks and quacks lack humility in the face of disease. They have confidence without knowledge. As a real doctor, I know, with complete certainty, that I will have failures. I know that there are some diseases I can’t beat. The variety, complexity, and horror of human diseases have taught me my place. I can’t promise miracles, but I can give statistics.

Quacks and cranks do promise the improbable. They promise to stop you from aging. They promise to stop autism by fighting vaccination. They promise to twist your chi until your malaise relents. Most important, they don’t know what they don’t know, and that makes them dangerous.

I sometimes wonder if surgical training and surgical culture, with its emphasis on confidence and action over introspection, makes surgeons particularly prone to quackery and crankery. Certainly, Dr. Roy Kerry, the head and neck surgeon-turned quack whose quackery killed an autistic child gives me pause, as does the case of Dr. Lorraine Day, a prominent academic orthopedic surgeon who embraced not only quackery but all manner of conspiracy theories, including Holocaust denial. Another thing that gives me pause is the number of surgeons who seem to embrace “intelligent design” creationism, including a prominent neurosurgeon and a general surgeon. I realize it’s a small sample, but I tend to wonder whether surgeons seem especially prone to the arrogance of ignorance when it comes to areas outside their expertise and prone to their confidence leading them astray within their field.

The bottom line is that practicing evidence- and science-based surgery is, as for all specialties, exceedingly difficult. Balancing the confidence to make a decision and persuade the patient of its correctness with humility in the face of disease, uncertainty, and conflicting evidence, leavened with a firm knowledge of facts and the scientific method sufficient to allow a surgeon to interpret the data in the light of his or her own experience and the unique situation of the patient and then apply that interpretation in a manner most likely to benefit that patient, represents the core of surgical excellence. This knowledge and these skills are very hard to acquire and teach, but not by any means impossible if the teacher wants to teach them and the learner wants to learn them.

19 thoughts on “On humility, confidence, and science-based surgery”

“Add to this mix patient expectations. When I first started practicing after leaving fellowship, I thought that the best approach was to lay out the surgical options, the risks and benefits of each based on my best interpretation, and to try to let the patient decide, with my advice as needed. I soon found that this was a problem.”

A large part of a patent’s assessesment of risk, when someone they don’t know at all well is proposing cutting into them and re-arranging their insides, may hinge on their assessment of the surgeon. Since they seldom know anything of the surgeon’s performance figures, this assessment will rest with the signals he/she gives in consultation, including things like tone of voice, eye contact and percieved confidence. That may be the only reason they trust them to do good not harm! Amazingly, it generally works.

I want the most confident surgeon. I disagree that arrogance, confidence, and humility are on a continuum. They may be conceptually related but not labels on a single scaled construct. No one died from an overconfident surgeon, an inept one or an ignorant one, a misinformed one certainly; but, never was confidence a problem.

Seriously? I’ve seen the occasional horrendous complication due to a surgeon being overconfident, and I’m not talking about bad surgeons, either. For example, I remember an incident many years ago when I was a resident in which, instead of reversing the coumadin on a patient who needed an urgent operation (the operation wasn’t so urgent that it couldn’t have waited for us to give a little fresh frozen plasma and vitamin K to reverse it), a surgeon was so confident that he could handle it without waiting. He was so good that I didn’t question it. Guess what? The patient had postop bleeding that required reoperation. So, yes, overconfidence, even in a really good surgeon, can result in serious complications.

One of my favorite movie lines comes from Dirty Harry in Magnum Forcewhen he says, “A man’s got to know his limitations.” That is especially true of a surgeon.

@windriven – note what follows though, Jay Lee places the blame for errors on ineptitude, ignorace and misinformation. It’s arguable (and a bit hair-splitting) the degree to which overconfidence and skills can be blamed for unsuccessful failures in surgery. Not being a doctor, I see it as a bit of a semantic argument – perhaps doctors see things differently.

Perhaps it does boil down to definitions. If one is a surgeon of objectively modest skills who has struggled through, say, a Whipple years ago during residency yet 20 years later is confident in his ability to perform one at his 150 bed hospital, I would brand that as overconfident. The surgeon is not incompetent, though not particularly gifted. The surgery is difficult but not beyond the pale. A prudent and confident surgeon might invite a colleague with contemporaneous Whipple experience to assist. An overconfident surgeon would say, “what, me worry?”

Second try. First one failed to clear moderation for inscrutable reasons. I suspect the NSA

Perhaps it is an issue of definitions. Let’s assume a surgeon of modest skills who last struggled through a Whipple during residency. Now, a decade later, he is going to do one at his 150 bed hospital in deep suburban Duluth.

By my definition set a confident surgeon would invite a colleague with recent history doing successful Whipples to assist. An overconfident surgeon would plunge ahead.

The surgeon is not inept; he has, in fact, performed the procedure before. He is not ignorant; he knows the procedure is fairly intricate and taxing. He is not misinformed; the Whipple is performed today largely as it was during his residency.

Most disturbing, WLU. I replied an hour or so ago and when I checked the reply had vanished. Refreshed the browser but still lost to the cosmos. So I wrote another and submitted it. Mirable dictu! The original and its replacement now appear.

Here’s hoping that the moderator du jour deletes one of them and this as well.

It depends. Certain surgical techniques—cough, cough, robotic surgery—have never convincingly been shown (at least to me) to be better than the techniques they are replacing (laparoscopic surgery). They are, however, much glitzier and higher tech, not to mention more expensive.

Maybe it’s because no one’s figured out how to use robotic surgery for breast surgery, and maybe I’d be a lot more enthusiastic if I could play with the surgical robot too.

In my home state some years ago they planned to introduce a list of surgeons, the operations they performed, and their complication rate. This was abandoned when it was pointed out that less skilled surgeons would often refer difficult cases to more skilled specialist surgeons. The complication rates of these specialist surgeons would often be much greater than those of less skilled surgeons because of the fact that they handled the more complicated cases.

So maybe you should pick the surgeon with the greatest complication rate! |:

I honestly don’t have an answer here. It’s so far beyond my experience and understanding that I won’t even venture an opinion. I’ve had surgery exactly once (twice if you count a suspicious spot on my toe), and I am extremely grateful for that fact. I pretty much engineer my life around trying to avoid drugs and surgery if at all possible, because even though they are life-saving or pain-sparing, you’re better off without them. I can’t imagine how Dr. Gorski or other surgeons have the confidence to do what they do, but I am extremely grateful that they reflect on the seriousness of their occupations.

Sorry, you know I love a good argument (even a pointless one – I’m looking at you Kombucha!) but I’m too far out of my depth to debate on this one

Earlier in my career I spent an awful lot of time in ORs. I’ve seen my share of vascular, cardio-thoracic, orthopedic (my least favorite), breast, AAA (probably my most favorite*) surgeries. I have towering respect for great surgeons – and there are lots of them. They do incredible things and make it look … not so much easy as … routine. But the best of them that I have known have always been keenly aware of their own areas of greatness but also areas where they do not have depth (sometimes masked with ‘I don’t waste my time with that $&!#’). I’ve also had the misfortune of meeting a few who apparently did their residencies in Ulan Bator under the tutelage of an ox butcher. More unfortunate still, some of those ended up in rural VA hospitals when they couldn’t maintain privileges in the city. Rural VAs – at least back in the day – were sometimes dumping grounds for physicians hanging on by a thread.

*I once saw emergency surgery on a state police officer who shot himself accidentally while preparing for his shift. The surgeons had his entire bowel reflected in an attempt to seal all the bleeders. He expired on the table. It was a freaking zoo. At one point there must have been 25 people in the OR (this was a teaching hospital). Am eye-blink after they called it, the place was empty. For a physicist masquerading as an engineer with no academic background in medicine, it was a profound experience. But it was so sad that it could never be among my favorites.

As a veterinarian , I also had to deal with the question of , Should I perform this surgery or should I send the dog/cat to the specialist surgeon.
I always felt that my most important role was to attempt, as best I could, to pass on what knowledge and skilIs that I could, to my juniors. I am pleased to say, that my small part in this process led to one of my juniors becoming a very good surgeon.